Observations and sepsis flags

Question 1

Normal heart rate - < 1 year old

Answer 1

110 - 160 bpm

Question 2

Normal heart rate - 1 -2 year old

Answer 2

100 - 140 bpm

Question 3

Normal heart rate - 2 - 5 year old

Answer 3

95 - 130

Question 4

Normal heart rate - 5 - 12 year old

Answer 4

80 - 120

Question 5

Normal heart rate - >12 year old

Answer 5

80 - 100

Question 6

Normal systolic BP - <1 year old

Answer 6

70-90

Question 7

Normal systolic BP - 1 - 2 year old

Answer 7

80-95

Question 8

Normal systolic BP - 2 - 5 year old

Answer 8

80-100

Question 9

Normal systolic BP - 5 - 12 year old

Answer 9

90-110

Question 10

Normal systolic BP - >12 year old

Answer 10

100-120

Question 11

Normal respiratory rate - <1 year old

Answer 11

30 - 40

Question 12

Normal respiratory rate - 1 - 2 year old

Answer 12

25 - 35

Question 13

Normal respiratory rate - 2 - 5 year old

Answer 13

25 - 30

Question 14

Normal respiratory rate - 5 - 12 year old

Answer 14

20 - 25

Question 15

Normal respiratory rate - >12 year old

Answer 15

15 - 20

Question 16

<5 Sepsis risk

Colour - low risk

Answer 16

Normal colour

Question 17

<5 Sepsis risk

Colour - intermediate risk

Answer 17

Pallor noted by parent

Question 18

<5 Sepsis risk

Colour - high risk

Answer 18

Pale
Mottled/ashen
Blue

Question 19

<5 Sepsis risk

Activity - low risk

Answer 19

Responds normally
Smiles
Awakens quickly
Not crying/normal cry

Question 20

<5 Sepsis risk

Activity - intermediate risk

Answer 20

Abnormal response
No smile
Prolonged stimulation to wake
Decreased activity

Question 21

<5 Sepsis risk

Activity - high risk

Answer 21

No social cue response
Looks ill to healthcare
Does not stay awake
Cry: weak/high-pitched/continuous

Question 22

<5 Sepsis risk

Circulation - low risk

Answer 22

Normal skin/eyes

Moist mucous membranes

Question 23

<5 Sepsis risk

Circulation - intermediate risk

Answer 23

Tachycardia
CRT >=3s
Dry mucous membranes
Poor feeding in infant
Reduced urine output

Question 24

<5 Sepsis -

High risk: Circulation

Answer 24

Reduced skin turgor

Question 25

<5 Sepsis risk

Other - intermediate risk

Answer 25

T >=39 in 3-6m
Fever 5+ days
Rigors
Limb/joint swelling
Non weight-bearing/non-use

Question 26

<5 Sepsis risk

Other - high risk

Answer 26

T >=38 in <3m
Non-blanching rash
Bulging fontanelle
Status epilepticus
Focal neurology
Focal seizure

Question 27

<5 Sepsis risk

Resp: intermediate risk

Answer 27

Nasal flaring
RR >50 in 6-12m
RR >40 in >12m
Sats <=95% in air
Crackles

Question 28

<5 Sepsis risk

Resp: high risk

Answer 28

Grunting
RR >60
Moderate/severe recessions

Question 29

WCC

Answer 29

4.0 - 11.0 x 10^9/l

Question 30

Neutrophils

Answer 30

2.0 - 7.0 x 10^9/l

Question 31

Lymphocytes

Answer 31

1.0 - 3.0 x 10^9/l